PDF FMCSA Form OCE-46

FORM OCE-46 Revised 09/27/2017

OMB No.: 2126-0018 Expiration: 09/30/2020

A Federal Agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0018. Public reporting for this collection of information is estimated to be approximately 15 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, Washington, D.C. 20590.

United States Department of Transportation Federal Motor Carrier Safety Administration

Office of Registration and Safety Information: Request for Revocation of Authority Granted

FORM OCE-46

Docket Number:

Name of carrier, freight forwarder, or broker making request:

Address of requesting carrier: Street:

City:

State/Province:

ABCDFGHIKLMNOPQRSTUVWYdlnoaoleruhaoelmriuthknaoiwadosbiraeyunlxikenlrocskbvwntlarekihznsgtbaioehmatrsingohctfarsoidmuybncktahsiowfrathdmuosngarihdBHJMYsnetoliatenvVicomSgueiarsyonwcasnCDicuraosCDntdinaErIkcilanhCsRberminulostgeavpsnrtomnleiastdxyianueiltnsgokarpcendkIftraickowtsyMonailpuscoSinlCueoanTlwaoistlatditaminohrantemiansrdclriabduiarkoaeIisamnastnolabadrsniiaeLdsabrador

Postal Code:

For the reasons stated below, this carrier, freight forwarder, or broker, which is the holder of the above-identified permit(s), certificate(s), or license(s), hereby requests revocation of such registration to the extent specified, in accordance with the provisions of 49 U.S.C. 13905.

Please select authority type (check all that apply):

Common

Contract

Broker

Reason for request of revocation:

It is clearly understood that upon revocation of this registration, operations that are revoked may not be resumed unless this authority is reinstated or other registration has been issued.

Name of person authorized to submit this request (please type or print):

Daytime telephone number:

Signature of person authorized to submit this request:

Date:

/

011234567890

01231234567890

/ 2018

Note: Signature must be notarized or signed in the presence of a FMCSA staff member.

Affix Notary Seal

City/County:

Subscribed and sworn to before me this 123456789snrt0123456789htdtsnrdhtdd

Notary Signature:

State/Province: ABCDFGHIKLMNOPQRSTUVWYADLNCDKLMAERWCNXITAOSYBKLRZUCETDHJMVNIABDEHINOPSTVY

day of JFMASONDauepueocnlapbyctrgvuryetroeiuceualbmhmsraetyrbrbyeerr

, 2018

My commission expires on:

/

011234567890

01231234567890

/ 2028

Name/Title of witnessing FMCSA staff member (please type or print): FMCSA staff member signature:

Witnessed on:

/

011234567890

01231234567890

FORM OCE-46 Page 1 of 2

/ 2018

FORM OCE-46 Revised 09/27/2017

OMB No.: 2126-0018 Expiration: 09/30/2020

Please return Form OCE-46, Request for Revocation of Authority Granted, to:

Federal Motor Carrier Safety Administration Office of Registration and Safety Information 460 Industrial Blvd. London, KY 40741

The original form must be submitted. Faxed, E-mailed, or photocopied forms will not be accepted. The attached Form OCE-46, Request for Revocation of Authority Granted, must be completed in its entirety (docket number/MC, complete name and address of the carrier, and authorized signature) and notarized, in order that FMCSA may process your request. All questions should be directed to the Office of Registration and Safety Information at (800) 832-5660.

FORM OCE-46 Page 2 of 2

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